The letter stated: 'All parts of the NHS in North West London are working together with local people to develop a long term strategy that improves health and care and ensures robust, high quality services for all our patients. That strategy will be our local response to the NHS Long Term Plan. We expect to publish the final version of our local five year strategy in November 2019; a draft will be circulated in September 2019.

'At the same time, we face an immediate challenge, with our sector as a whole forecasting a significant financial shortfall this year. As such, alongside our longer-term planning, we are developing a financial recovery plan to get us back on track, so that we can focus on the improvements we need to make for the future.'

The CCG said it will look at acute contracts held by primary care networks and practices to address any excessive acute treatment activity.

A spokesperson for NWLCCCG said: 'We want to work with GPs to understand why growth is in excess of contract and understand whether there are other alternative ways of dealing with the patient’s needs. There are big differences in between practices in terms of referral rates, so this will be an opportunity to share learning and best practice across all eight boroughs in North West London.'

On referrals, they said: 'We will not restrict referrals between specialties within agreed pathways, and nor will we do so in case where patients require an urgent opinion. However, we do need to work out why there has been such apparent unplanned growth, make sure the coding is correct and stop inappropriate referrals.

'All outpatient specialties will continue to deliver follow-up care and procedures. For some patients this might be best provided by a community service or via a telephone appointment. The right follow-on care and advice does not always need to be provided by a consultant at a hospital.'

BMA London regional council chair and London GP Dr Gary Marlowe is concerned by the lack of GP input in the CCGs' decisions, warning these should not be done to the detriment of patient care or increase workload.

He said: 'We appreciate that all CCGs are dealing with intense financial pressure, and it's only right that commissioners look at inefficiencies and areas of wastage to ensure that their funds are being used appropriately, responsibly and to ensure the best for patients.

'Meanwhile, if too many patients are attending A&E then the CCG is right to ask questions about what other options are available – though much of this well depend on a well-functioning and well-funded primary care system locally.

'However, cost-cutting must not come at the expense of quality patient care or increased bureaucracy and workload for doctors.'

He added: 'All clinicians – whether in GP practices or in hospitals – must be able to make decisions over what is best for the patient in front of them, based on their own clinical evidence base, and not be blocked by arbitrary money-saving restrictions.'

Labour MP for Hammersmith Andrew Slaughter said: 'GPs are being told not to refer patients to consultants unless absolutely necessary and then only to those at the local hospital trust where waiting times could run to six months or more.

'The restrictions on consultant to consultant referrals will hit those with the most complex and difficult conditions hardest. This attacks the whole basis on which the NHS operates and gives the lie to Boris Johnson’s claims of support.'

Readers' comments (2)

"-Repatriation of 15% of elective work referred out of sector back to acute providers;
-Significantly reducing consultant to consultant referrals, follow ups and outpatient procedures;
-Reducing the £18m spent on over-the-counter medicines."

Sound like generating a lot of extra work for GPs - an area which is not exactly overflowing with surplus resources.

It will have a knock on effect that is hard to measure beforehand, but that does not make it any less expensive. Just because it is hard to predict how expensive that will be - does not mean it should be ignored.

Emergency hospital admissions can be reduced by taking work away from GP practices - not by creating more work for GP practices.
That will save a lot more money than a few dodgy referrals.

If you don't want consultants to do the referrals - then commission a service (not involving GPs!) to do the work instead. P erhaps a group of nurses and administrators that actually manage the referrals (getting all the workup done and organising and acting on advice) rather than just a yes/no gate.

That is likely to be much cheaper than using GPs overall - it is just that the funding has to come out of the CCG rather than out of the other workload of the GPs.